Provider Demographics
NPI:1639310261
Name:GREENHAW, JOHNNY (MA, CADC II,)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:GREENHAW
Suffix:
Gender:M
Credentials:MA, CADC II,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 SPAANS DRIVE STE C D & F
Mailing Address - Street 2:
Mailing Address - City:GALT
Mailing Address - State:CA
Mailing Address - Zip Code:95632-1658
Mailing Address - Country:US
Mailing Address - Phone:209-744-9909
Mailing Address - Fax:209-744-9910
Practice Address - Street 1:750 SPAANS DR STE CD&F
Practice Address - Street 2:
Practice Address - City:GALT
Practice Address - State:CA
Practice Address - Zip Code:95632-8609
Practice Address - Country:US
Practice Address - Phone:209-744-9909
Practice Address - Fax:209-744-9910
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-11
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 171M00000X, 390200000X
CA12211101YM0800X
CAA020520815101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program